La. Admin. Code tit. 40 § I-311

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-311 - Employer, Insurance Carrier, Managed Care Organization, or Agents' Receipt of Medical Bills from Health Care Providers

A. Upon receipt of medical bills submitted in accordance with Sections 305, 307, and 309 of this Chapter, an insurance carrier shall evaluate each bill's conformance with the criteria of a complete medical bill.

B. The received date of an electronic medical bill is the date all of the contents of a complete electronic bill are successfully received by the insurance carrier.

C. The insurance carrier may contact the medical provider to obtain the information necessary to make the bill complete.

1. Any request by the insurance carrier or its agent for additional documentation to pay a medical bill shall:

a. be made by telephone or electronic transmission or through web portal access if available unless the information cannot be sent by those media, in which case the sender shall send the information by mail or personal delivery;

b. be specific to the bill or the bill's related episode of care;

c. describe with specificity the clinical and other information to be included in the response;

d. be relevant and necessary for the resolution of the bill;

e. be for information that is contained in or in the process of being incorporated into the injured employee's medical or billing record maintained by the health care provider; and

f. indicate the specific reason for which the insurance carrier is requesting the information.

2. If the insurance carrier or its agent obtains the missing information and completes the bill to the point it can be adjudicated for payment, the insurance carrier shall document the name and telephone number of the person who supplied the information.

D. An insurance carrier shall not return a medical bill except as provided in Subsection A of this Section. When returning an ASC X12N 837 medical bill, the insurance carrier shall clearly identify the reason(s) for returning the bill by utilizing the appropriate reason and rejection code identified in the standards identified in Section 305. A of this Chapter.

E. The proper return of an incomplete medical bill in accordance with this Section fulfills the obligation of the insurance carrier to provide to the health care provider or its agent information related to the incompleteness of the bill.

F. Insurance carriers must timely reject bills or request additional information needed to reasonably determine the amount payable.

1. For bills submitted electronically, the rejection of all or part of the bill must be sent to the submitter within two business days of receipt.

2. If bills are submitted in a batch transmission, only the specific bills failing edits shall be rejected.

G. If an insurance carrier has reason to challenge the coverage or amount of a specific line item on a bill, but has no reasonable basis for objections to the remainder of the bill, the uncontested portion must be paid timely, as in Subsection H of this Section below.

H. Payment of all uncontested portions of a complete medical bill shall be made within 30 calendar days of receipt of the original bill, or receipt of additional information requested by the insurance carrier allowed under the law. Amounts paid after this 30 calendar day review period shall be subject to R.S. 23:1201(F).

I. An insurance carrier shall not return a medical bill except as provided in Section 311. A of this Chapter. When returning a medical bill, the insurance carrier shall also communicate the reason(s) for returning the bill.

J. The insurance carrier's failure to comply with any requirements of this rule shall result in an administrative violation in accordance with LAC 40:109.A.

La. Admin. Code tit. 40, § I-311

Promulgated by the Louisiana Workforce Commission, Office of Workers' Compensation, LR 37:3546 (December 2011), Amended by the Workforce Commission, Office of Workers' Compensation Administration, LR 412692 (12/1/2015).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.2.